Objectives of the Mitanin Programme :

The fundamental principles of the Mitanin Programme :andThe Challenge of Large Scale Government led Community Health Worker Programmes

Improve awareness of health and health education. Improve utilisation of existing health care services Provide a measure of immediate relief to health problems. Organise community ,especially women and weaker sections on health care issues Sensitise panchayats and build capabilities Objectives of the Mitanin Programme:

Operational Objectives • 1. Select a Mitanin in every hamlet of the state- 60,000 in all. • 2. Train the Mitanin over 18 months- 20 days of camp based training and 30 days of on the job training at the village. Induction training. Then 12 days of camp based and 30 days of on the job every year. • 3.Provide support to Mitanin in her in her work and closely coordinate with ANM and AWW for maximal effectiveness.

We know that CHWs can make a major impact on child survival: The case of Jamkhed, Maharashtra • Prompt first contact “life saving” visits- diarrhoea, ARI & fever • Home based newborn care, • Facilitate closure of service gaps (esp. immunisation & ANC.) • Referrals- sick child and neonate. • Child nutrition counseling. • Key messages/practices that every family will know/change. :

Earlier Programmes • Community Health Worker- Jamkhed, SEWA Rural, Mandwa(FRCH), RUHSA,(Vellore), SEARCH( Ghadchiroli),VGSS; • Community Health Worker – 1977 • Village Health Guide- 1984 • Link Worker & Depot holder • JanSwasthya Rakshak- 1997

“4692 subcenters, 26,000 villages and 54,000 hamlets- For improved child survival every newborn, every diarrhoea, every ARI, every case with fever- must be seen on Day One. Just not possible for a govt cadre Govt programmes do not succeed without Community Support- and this requires investment in systematic community processes Health education requires someone from within the community who knows the local dialect, base line knowledge, idiom and perceptions, What are the Compulsions for a Community health volunteer?

The spirit of a CHW programme • Health is not a commodity that a benevolent state can force a reluctant population to consume!!!! • Health is a set of processes that occur at the level of the family and the community in the context of their daily working and living conditions. “Peoples Health in Peoples Hands” “Hamaar swathya hamaar haath”

Spirit of the programme • Free health care services is not an act of compassion for the poor. • Health care service is an “entitlement” – a basic human right!! “Swasthya Hamar Adhikar Havai” .

Earlier Programmes: Largely Men Community Health workers esp in JSRs and CHWs Mitanin Programme: Only Women Perception of Health as a value in itself. More concern on health – in family and in society More focus on health education Less interest in becoming a quack Earlier Programmes and Mitanin Programme- Comparisons

Earlier Programmes: Usually by health staff Or by Panchayats- as representing the community-but panchayats often represent vested interests & health staff seek docile help not partnership- Mitanin Programmes: By the general body of the village; Subject to approval of the village: After both of the above have been sensitized by meetings conducted by trained facilitator and mobilized and motivated by specific processes like kalajatha. The Selection Process

Usually one for village One for each hamlet Better coverage Effectively handles issues of marginalisation of some communities Compatible with voluntarism.. The level of operation/coverage

Earlier Programmes “ because without catering to felt need one cannot moblise for prevention” In NGO CHW programmes effective curative care demonstrated but little preventive or promotive indicators studied In govt programmes eg JSR only poor quality curative care remained;No specific plans for preventive /promotive work Mitanin Programme “ curative care supplementary- not central” Introduced in training only after all other preventive and promotive aspects of the programme are trained and deployed and assessed: Effective plans for preventive and promotive care and indicators chosen and used( I.M.C.I ; health education, local planning etc ) Curative centeredness

Earlier govt. programmes Drugs had to be prescribed No referral systems User fees and prescribed drugs actively encouraged in the JSR and similar programmes. Mitanin Programme Drugs provided by the government Active referral system Resisting harmful curative care made part of the programme Tendency to “quackery”

Earlier programmes; Honorarium drives and ensures participation- in training( for JSR) and in work ( for CHW). Mitanin Programme: No honorariums: Performance based incentives used. Motivation and support has to sustain participation The honorarium issue

For: needs compensation for loss of livelihood. When everyone else is paid – why not this volunteer- it is discriminatory and unfair. We cannot secure participation without it We cannot sustain participation without it and it is difficult to retrain every time there is a drop out. Against: Only that much work given as can be done without loss of livelihood Should be seen as representative of community, -paying her is inadequate for livelihood but makes her lowest paid employee of department Safeguards selection process from pressures and vested interests. The arguments for and against honorarium

But we also know that too often such models have failed: Why is it that • Small Scale CHW Programmes with NGO leadership – Flourish. • while Large Scale Programmes – which are Government organised – Do poorly

So what is lost with scale.. 1 Motivated Leadership: The Antia Factor.. “Its alright one can do it in Jamkhed or in Mandwa- but how can one get an Arole or an Antia or an Abhay Bang in every place….” • Requirement … one “Antia per every 30 villages or at least every 150 villages. Chhattisgarh would require approximately 2000 Antias • The commitment and the costs…

And what else goes 2. Quality of Training: the problem of transmission loss in the training cascade.. 3. Quality of Trouble-shooting– On the Job Support… 4. Quality of Monitoring…Identifying the weak areas and responding to them.

And further lost with scales are… • Quality of Referral Support in the CHW programme: ( reform in institutional structures that play higher order roles needed to complement and later sustain the programme). • A tradition of working with local community that provides links. • An ability to persist, learn and correct.. • Evaluation: manage able Sample Size and representative qualitative inputs.

Referral Support & the Mitanin Programme • All small NGO programmes had a very good base hospital with a medical team. • But when we scale up the PHC and CHC have to play this role. • Not a problem, not just an opportunity but part of the purpose itself. • Mitanin Programme becomes an idiom of health sector reform and some of this may outlast the Mitanin itself!!!!

Mitanin as Health Sector Reform.. • The creation of the SHRC. • The linkage of funds flow of Mitanin programme to developments in all parallel areas of public health system strengthening.( over 14 specific dimensions ) • The 39% increase in state budget- the over 50% increase in total public health expenditure.( but now reached 4% of outlay) • The creation of 874 HSCs, 200 PHCs and 16 CHCs to close all institutional gaps, the move to 2 doctor PHCs, the 4 specialist , 7 doctor CHC, the pressure to make FRUs functional, the opening up of ICDS centers.. • Major programme of CHC & PHC improvement Long way to go.. But the Mitanin is the flagship.. Bringing health one step further on the political agenda. In myriad number of ways.. Eg increasing immunisation on hearing the announcement / effect on the visiting CMs and VIPs….the flow of aid… etc.

Securing community level processes in the Mitanin Programme • In absence of long involvement with local community( and even if..) who speaks for the community?? In NGO programmes we have a discerning listener… Whose gaze defines what is spoken… • But when the dt administration gives the appeal.. Either the panchayat elite appropriate the voice, or the department functionary does. Who informs the community, who enthuses the individuals? Who amplifies the voice of the weak? • Hence the need for the trained facilitator- the prerak- and for a defined process of social mobilisation- songs and plays taking through the spirit of the programme. • But who selects the prerak? Need to define a set of processes and have a support structure to guide this Principle: An intermediary force is a must but such a force brings with it a new set of problems …

Programme duration as a variable • Need to allow for programme structures and personnel to evolve. • Need to allow for people to come in and leave and others to come in • And after a structure stabilises one needs to do and re-do many parts of the programme.. And all this needs time and persistence with the programme and learning curves….. • This happens in small programmes too – but external documentation often misses it as compared to first person accounts.. But it needs to be built in. • Mitanin Programme went two moults and is in the third.

Pace of the Programme as a variable.. • Need to sustain pace of the programme for both the effect of social mobilisation and to keep it on the political agenda. • Enough time to allow for a minimum set of well defined processes and enough to allow for evolution of structures.. And constant corrections.. But longer duration by itself is not a virtue… And one needs constant innovation

Staggering the Programmes- 3 critical steps • Pilot phase – builds the tools -builds the state leadership- tends to do poorly. 14 blocks- • First phase- builds the district teams, gets the systems in place- 66 blocks • Second phase-- reaches out to full coverage --66 blocks.. • Subsequent phases- re do various aspects, bring in corrections , innovations etc.-

Addressing Transmission losses in training cascades.. Three Key Steps : • High voltage: Capable full time top of the pyramid: key resource persons- full time hand-picked and personally trained team. • Good conductors: Insistence on systematic use of training material. • Step up transformers: Use of training evaluation (and on the job back up).

Emergence of a training cadre.. • Whether and how --Related to existing human resource availability. • Do we have surplus ANMs…even outside the government employment( like in andhra pradesh) • Can the existing ANM play this role? • Do NGOs have the required persons or expertise? • This cadre needed in monitoring and provision of on the job training. • But would have low/zero clinical skills. • All experience would eventually be learnt from the field and limited by the quality of supervision possible. • Needs strategy of trainer recruitment and replacement and evolution of this workforce. • Mitanin has now over 3000 trainers and 300 dt resource persons and 25 state trainers

Strategy of Monitoring The small NGO programme relies on the review meeting. But in the large programme …. • Need to put in place a set of defined processes- the cluster meeting, the block trainers review, the district coordination meeting, the state nodal officers review, the state field coordinators review. • Need to put in place a large workforce to do this- the trainers cadre.. The nodal officer heirarchy.. The field coordinator. • Need to carefully make a choice of Monitoring Indicators

Monthly Monitoring Indicators • New born visit and change in six practices • Over 10 to 20 ‘first day’ requests for curative care • Visit in last trimester of pregnancy and the plan for child-birth. • Attendance at the immunisation day.( convergence and service facilitation) • Knowing the children at risk and counselling. • DOTS provider role • The hamlet level meeting. Observable, Measurable, verifiable from parallel sources, aggregatable….

Evaluation • Getting sample sizes involves costs and research teams. • Needs clear definition of outcomes and its measurability. • Need care in relating processes to outcomes. • Qualitative studies needed to catch enormous diversity. • Qualitative studies needs training in qualitative methodology, the anthropologists or sociologists skills.. and this is difficult to obtain and even more difficult to standardize. • Internal evaluation with in built externality with key processes under qualitative study offers a way forward. • To be wary of experience- need to have grounding in methodology.

How to get an Antia everywhere… The Gaussian curve: • All biological and most social systems display a bell shaped ‘ normal’ distribution. So too should motivation..5 to 25 % in any group of a reasonable size- will potentially have a sense of motivation- to work with self lessness. Whether it be NGOs or government officers or BEEs • And one needs to have a way of searching for and finding this 5%. How to sift through – and how to adsorb onto the system..

The Power Principle • Needs to define the determinants of the x – axis location of the system- where motivation is on the y- axis.. • There are relationships of power embedded in • Knowledge…. • Institutional structures • Mind-sets/attitudes… • Programme designs- • Not just the key decision – but every single detail is power-laden!! • Relationship to these define the x- axis of motivation. • And the leadership needs to be able to question existing relationships in all of these domains. And that indeed defines leadership • Need to have the catalyst in place who can constantly work on redefining these determinants…at every level.

Uneven Pace of Progress.. Categorised into 4 groups: • A-(>75%) 16 blocks • B- (55-75%)47 blocks • C- (35- 55%)63 blocks • D- ( <35%)20 blocks % of Mitanins functional as averaged for these 6 parameters

Trends In Rural & Total IMRIndia, MP & Chhattisgarh orZeku fLFkfr NRrhlx<+ fuekZ.k ij NRrhlx<+ fuekZ.k ij orZeku fLFkfr As Per SRS Data

The recipe…. • Get a mix of state and civil society at every level. – never one or the other alone.. Carefully define the institutional mechanisms for this • Let structures/ key persons evolve with considerable flexibility and innovation.. • Put in a strong dose of social mobilisation- questioning existing values –eg patriarchy, caste symbols, • Have a catalyst- the facilitator- in place to absorb the right persons and highlight , support and build capabilities in- to mentor. • Negotiate, negotiate, negotiate-

Thank you

Objectives of the Mitanin Programme :